Shoulder Pain Review of Physical Exam and An Approach To The Differential Diagnosis
David G. Liddle, MD Assistant Professor of Orthopedics Assistant Professor of Internal Medicine Vanderbilt University Medical Center Nashville, TN
Vanderbilt Sports Medicine Disclosures • No financial disclosures or conflicts of interest
Vanderbilt Sports Medicine Objectives
• Review pertinent anatomy and pathology associated with common causes of shoulder pain • Review historical and physical exam findings that help differentiate common causes of shoulder pain • Review imaging findings relevant to these causes of pain and discuss a rationale for appropriate use of diagnostic tests • Review the best evidence available to the guide treatment of these conditions
Vanderbilt Sports Medicine Vanderbilt Sports Medicine Syst. Reviews of RCT
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Vanderbilt Sports Medicine Anatomy Review
http://www.aafp.org/afp/2004/1115/p1947.html http://www.bandhayoga.com/images/Blog/blog2 Vanderbilt Sports Medicine 3_serratus_anatomy.jpg XR Review AP Int. & Ext. Rotation & Axillary views +/- Scapular-Y view
Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain
Non-Operative Operative &/or Non-Op • Subacromial Impingement • Rotator Cuff Tear • Subacromial Bursitis – Acute, Known Injury • Adhesive Capsulitis – Chronic, Unknown Injury – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability
Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain
Non-Operative Operative &/or Non-Op • Subacromial Impingement • Rotator Cuff Tear • Subacromial Bursitis – Acute, Known Injury • Adhesive Capsulitis – Chronic, Unknown Injury – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability
Vanderbilt Sports Medicine Shoulder Pain Radiating Patterns • Sternoclavicular Joint Up SCM/Front of Neck • Acromioclavicular Joint Upper Trap/Lat. Neck • Subacromial Space Lateral Brachium • Biceps Tendons Anterior Brachium
Vanderbilt Sports Medicine Subacromial Impingement History Exam • Pain radiates from superolateral • Scapular dyskinesis on forward shoulder to lateral brachium elevation (FE) • Pain with reaching • Limited passive internal rotation (IR) • No rest pain • PROM ≥ AROM – Different than sleep/night pain… • Tender To Palpation at Coracoid this will hurt • Pain AND weakness on Empty-Can – Rest = Sitting with hands in lap testing at 90 ABduction in scapular • Usually insidious onset plane but NL at 30 and other Rot. • May be capped by an event or start Cuff/Shoulder/Arm muscle strength NL some time after an event • Pain AND Weakness resolve/improve • Primary or Secondary disorder with scapular retraction test • No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests Neck ROM Vanderbilt Sports Medicine Scapular Dyskinesis
http://www.youtube.com/watch?v=ROsiiDsjm2o Vanderbilt Sports Medicine Empty-Can Test
Vanderbilt Sports Medicine http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-16a.jpg Scapular Retraction Test
Vanderbilt Sports Medicine Kibler WB. Br J Sports Med 2010 Neer’s and Hawkins’ Tests for Impingement
Vanderbilt Sports Medicine http://thepainsource.com Subacromial Impingement Imaging Treatment • 3-4 views of the Shoulder • Rehab – AP Int. & Ext. Rotation & – Strengthen Scapular Stabilizers Axillary +/- Scapular-Y view • Rhomboids, Middle Trapezius, – Usually normal Serratus Anterior • Obtain these in setting of – Stretch Tight Posterior Capsule and Pectoralis Minor injury and/or to screen for calcific rotator cuff • Subacromial CS Injection tendonopathy or – To improve tolerance for Rehab osteoarthritis • Subacromial Decompression • Neck XR only if reproducible only if conservative Tx fails radicular signs/symptoms
Vanderbilt Sports Medicine Calcific Rotator Cuff Tendonopathy
Vanderbilt Sports Medicine http://www.orthopaedicsone.com/display/MSKMed/Calcific+tendonitis+of+the+shoulder Calcific Rotator Cuff Tendonopathy Treatment • U/S Guided Lavage & CS Injection; Debridement if too large or failed CSI
Vanderbilt Sports Medicine http://www.ultrasoundcases.info/files/Jpg/lbox_22380.jpg http://www.nguyenthienhung.com/2012_09_01_archive.html Subacromial Bursitis
physioworks.com.au Vanderbilt Sports Medicine Subacromial Bursitis History Exam • Pain radiates from superolateral • Scapular dyskinesis on fwd. elev. (FE) shoulder to lateral brachium • Limited passive internal rotation (IR) • Pain with reaching • PROM ≥ AROM but pain in all planes • (+) Rest pain of motion – Different than sleep/night pain… • Tender To Palpation deep to this will hurt acromion – Rest = Sitting with hands in lap • Pain AND weakness in all planes but • Usually rapid/sudden onset esp. on Empty-Can testing; Biceps – 10/10 Pain out of “Clear Blue Sky” and Triceps usually NL • May start soon after an event or • Symptoms may improve with recent incr. in activity scapular retraction test • No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests Neck ROM
Vanderbilt Sports Medicine Subacromial Bursitis Imaging Treatment • 3-4 views of the Shoulder • Subacromial CS Injection – AP Int. & Ext. Rotation & • PO NSAIDs +/- Narcotics Axillary +/- Scapular-Y view – Ketorolac (Toradol) – Usually normal • Rehab after pain improvement • Obtain these in setting of to address Impingement injury and/or to screen for • Subacromial Decompression calcific rotator cuff +/- Bursectomy only if tendonopathy or conservative Tx fails osteoarthritis • Neck XR only if reproducible radicular signs/symptoms
Vanderbilt Sports Medicine Adhesive Capsulitis
http://physioworks.com.au/images/Injuries-Conditions/Frozen_Shoulder_Adhesive_Capsulitis.jpg Vanderbilt Sports Medicine Adhesive Capsulitis History Exam • (+) Rest Pain • Limited passive IR > ER > Abd > FE – Rest = Sitting with hands in lap • PROM = AROM • Pain worse with reaching • Diffusely Tender To Palpation • Progressive Loss of Motion • Pain in all planes of motion may limit – IR ER & Abd FE strength – Motion returns in opposite sequence • Limited motion can prohibit Neer’s • Most common in Females, 40-60 y/o and Hawkins’ tests • May have autoimmune or chronic inflammatory etiology – Diabetes (25%), Hypothyroidism, IBD • Usually insidious onset • May be capped by event or the start some time after an event/trauma
• No change in pain w/ Neck ROM Vanderbilt Sports Medicine Adhesive Capsulitis
• Education & Expectations • Average of 9-18 months to run its course – Stage 1 – Freezing • Pain at rest AND progressive loss of motion – Internal Rotation External Rotation and Abduction Forward Elevation – Motion returns in opposite sequence – Stage 2 – Frozen • Rest pain resolves but severely limited motion and pain with reaching – Stage 3 – Thawing • ROM returns (IR last) and Impingement symptoms predominate – Stage 4 – Shoulder function is back to normal Vanderbilt Sports Medicine Adhesive Capsulitis Imaging Treatment • 3-4 views of the Shoulder • Education and Expectations – AP Int. & Ext. Rotation & Axillary • Glenohumeral CS Injection +/- Scapular-Y view – Level I – Superior to PO with fewer • Axillary view most difficult due to systemic effects; Repeat every 4-6 loss of motion weeks in Stage 1 and early Stage 2 – Usually normal Lorbach O et al. J Shldr Elb Sg. 2010 • Narcotics, Sleep Aids, NSAIDs • Rehab only AFTER Rest Pain resolves • Viscosupplementation – Level I – Not Clinically Significant Callis M. Rheumatol Int. 2006 • Manipulation Under Anesthesia if conservative Tx fails
Vanderbilt Sports Medicine Rotator Cuff Tear
orthop.washington.edu
Vanderbilt Sports Medicine http://stemcelldoc.files.wordpress.com/2009/01/mri-of-torn-rotater-cuff1.jpg Rotator Cuff Tear History Exam • Fall on outstretched arm • Limited AROM 2/2 weakness > – Abduction in scapular plane = pain but NL PROM Supraspinatus +/- Infraspinatus • Supraspinatus (70% of RCT) – External Rotation = Subscapularis – Weak Empty Can at 30 & Drop • c/o weakness > pain Arm test • Acute • Infraspinatus (20% of RCT) – Event after which c/o pain and – Weak ER & ER Lag Sign weakness and disability • Subscapularis (<1% of RCT) – ≤ 2-3 months – Weak IR & Belly Press or Lift Off • Chronic tests – Process/Gradual onset of weakness and pain – Event >3 months ago Vanderbilt Sports Medicine Drop Arm Test
http://www.youtube.com/watch?v=qvwYEoeHPaA Vanderbilt Sports Medicine Lag Sign and Belly Press Tests • Infraspinatus/Teres Min. Tear • Subscapularis Tear
Vanderbilt Sports Medicine http://www.psychiatrictimes.com/sites/default/files/rm/1628757.png http://www.psychiatrictimes.com/sites/default/files/rm/1628765.png Rotator Cuff Tear Imaging Treatment • 3-4 views of the Shoulder • Acute Tear = RCT Repair – AP Int. & Ext. Rotation & • Chronic Tear = Rehab Axillary +/- Scapular-Y view – Level II – 75% Return to NL Function – Usually normal & No Pain without Surgery at 2 yrs. – May show high riding humeral Kuhn JE. J Shoulder Elbow Surg. 2013 head above center of glenoid – Subacromial CS Injection for Pain • Loss of supraspinatus cap • Viscosupplementation • MRI if Acute RCT – Level I – Not Clinically Significant Chou WY. J Shoulder Elbow Surg. 2010 Meloni F. Eur J Radiol. 2008
Vanderbilt Sports Medicine Biceps Tendonopathy
Vanderbilt Sports Medicine http://chiropracticdubai.files.wordpress.com/2012/06/bicep-tendonitis-image1.jpg Biceps Tendonopathy History Exam • Pain radiates from anterior • Tender To Palpation overlying shoulder to anterior brachium proximal biceps tendon at bicepital • Pain with biceps flexion, especially groove with supinated wrist • Pain with extension of the shoulder • Usually insidious sudden onset • Pain with resisted supination of wrist • May start soon after an event or and resisted biceps flexion recent incr. in activity • Pain with Speed’s (resisted shoulder • Often accompanies Impingement flexion with wrist supinated and • No change in shoulder pain with elbow extended) and Yergason’s Neck ROM (resisted wrist supination with elbow at 60-90°) tests
Vanderbilt Sports Medicine Speeds’ and Yergason’s Tests
http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-17b.jpg Vanderbilt Sports Medicine http://www.studyblue.com/notes/note/n/upper-extremity-physical-exam/deck/6425897 Biceps Tendonopathy Imaging Treatment • 3-4 views of the Shoulder • Rehab – AP Int. & Ext. Rotation & – Eccentric Biceps exercises Axillary +/- Scapular-Y view – Stretch Biceps in extension – Usually normal • Tendon Sheath CS Injection • Consider MSK U/S • Topical or PO NSAIDs or APAP – Usually used to confirm if Dx is unclear on exam or if using U/S • Ionto/Phonophoresis for guided CS injection • Biceps Tenodesis if conservative Tx fails
Vanderbilt Sports Medicine Interim Summary • Was there an injury/event? Or was it a process? – Injury/Event – Rot. Cuff Tear, Subacromial Bursitis, AC or GH Dislocation – Process – Impingement, Frozen Shoulder, Biceps Tendonitis, DJD • Do they have “Rest Pain”? – No – Impingement, Rotator Cuff Tear (after initiating pain), Prox. Biceps Tear – Yes – Subacromial Bursitis (rapid), Frozen Shoulder (gradual), DJD (constant), AC or GH Dislocation (acute) • Where does it hurt? Where does the pain go? What causes it? – AC-Lateral Neck, Subacromial Space-Lateral Brachium, Biceps-Ant. Brachium – Tendonopathy hurts with palpation, stretch, and contraction • Appropriate XR will adequately address most shoulder pain – Always include an A/P Int./Ext. Rotation views with an Axillary view – If Acute Rotator Cuff Tear suspected MRI – If Glenohumeral Instability Scapular-Y Vanderbilt Sports Medicine Questions or Comments
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Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain
Non-Operative Operative &/or Non-Op • Subacromial Impingement • Rotator Cuff Tear • Subacromial Bursitis – Acute, Known Injury – Surgery • Adhesive Capsulitis – Chronic, Unknown Injury – Non-Op – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability
Vanderbilt Sports Medicine Proximal Biceps Tendon Tear Proximal Distal
www.eastbaysportsmed.com http://images.ookaboo.com/photo/m/Bicepstendon10_m.jpg
Vanderbilt Sports Medicine images.rheumatology.org Proximal Biceps Tendon Tear History Exam • Pain and/or pop at anterior • “Popeye Deformity” with defect shoulder but usually not painful proximal and bulge distal after initial event • ROM usually normal • May have bruising at anterior • May be Tender To Palpation at site of shoulder that tracks distally tear • Weakness on elbow flexion with hand in supinated position • Usually normal strength with hand at neutral or pronated
Vanderbilt Sports Medicine Proximal Biceps Tendon Tear Imaging Treatment • None required unless history • Reassurance of trauma • Surgery if – If trauma, XR to r/o fracture – Relative strength deficit is – MRI usually does not change intolerable or affects work/play management – Deformity is cosmetically unacceptable
Vanderbilt Sports Medicine Inflammatory Arthritides
Posttraumatic Osteoarthritis Arthritis
Shoulder Capsulorraphy Rotator Cuff Arthropathy Arthritis Arthropathy
Neuropathic Osteonecrosis Arthritis
Infection
Vanderbilt Sports Medicine Glenohumeral DJD History Exam • Pain deep in the shoulder • Limited P/AROM on IR/ER > FE that is constant; worse with • PROM = AROM reaching • Often have scapular dyskinesis – “Hopeless” pain • Usually NL Strength but may • (+) Rest Pain have Pain AND weakness on – Different than sleep/night pain… this will hurt Empty-Can testing at 90 – Rest = Sitting with hands in lap ABduction in scapular plane – May be weak w/ Rot. Cuff • Usually insidious onset Arthropathy • No change in shoulder pain • Pain AND Weakness may with Neck ROM resolve/improve with scapular
retraction Vanderbilt Sports Medicine Glenohumeral DJD Imaging • 3-4 views of the Shoulder – AP Int. & Ext. Rotation & Axillary +/- Scapular-Y view – Joint space narrowing, osteophytes, and humeral head and/or glenoid flattening
Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011
Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011
Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011
Vanderbilt Sports Medicine Glenohumeral DJD Treatment Non-Operative Operative • Physical Therapy • Non-Joint Replacement • Pain Medicine • Partial Joint Replacement – NSAIDs • Total Joint Replacement – Tylenol (APAP) • Reverse Total Joint Replacement – Narcotics • Steroid Injections • Viscosupplementation – Level I – Not Clinically Significant Blaine T et al. JBJS Am 2008 – Level II – Helps with Rotator Cuff Arthropathy Tagliafico A. Eur Radiol. 2011
Vanderbilt Sports Medicine AC Joint DJD
www.shouldersurgery.com.au Vanderbilt Sports Medicine AC Joint DJD History Exam • Pain radiates from superior • Tender To Palpation at AC joint shoulder to lateral neck and upper • Pain with Cross-Arm Adduction test trapezius • Likely will have secondary • Pain with reaching, especially Impingement signs across body – Scapular dyskinesis • Pain with pushups, bench press, – Limited passive internal rotation (IR) and overhead lifting – Symptoms resolve/improve with scapular retraction test • Aching rest pain – Pain with Neer’s and Hawkins’ tests • Usually insidious onset • No change in shoulder pain with Neck ROM
Vanderbilt Sports Medicine Cross-Arm Adduction Test
http://i3.ytimg.com/vi/fV97PJxXJQg/default.jpg http://www.massagetherapy.com/ce/content/images/664.jpg
Vanderbilt Sports Medicine AC Joint DJD Imaging Treatment • 3-4 views of the Shoulder • AC joint CS Injection – AP Int. & Ext. Rotation & • Topical or PO NSAIDs and Ice Axillary +/- Scapular-Y view • Rehab – Joint space narrowing and osteophytes – Addressing Impingement mechanics off loads the AC joint • Neck XR only if reproducible • Strengthen Scapular Stabilizers radicular signs/symptoms • Stretch Tight Posterior Capsule and Pectoralis Minor • Distal Clavicle Excision if conservative Tx fails
Vanderbilt Sports Medicine AC Joint Sprain
Vanderbilt Sports Medicine AC Joint Sprain History Exam • Fall onto/Blow to superolateral • Tender To Palpation at AC joint shoulder with ADducted arm • May have step off at AC Joint • Pain radiates from superior • Pain with Cross-Arm Adduction test shoulder to lateral neck and upper • Likely won’t have secondary trapezius Impingement signs unless they • Pain with reaching, especially present late across body • Pain can prohibit pushups, bench press, and overhead lifting • Aching rest pain • No change in shoulder pain with Neck ROM
Vanderbilt Sports Medicine AC Joint Sprain Imaging Treatment • 3-4 views of the Shoulder • Type I and II – Non-Op – AP Int. & Ext. Rotation & Axillary – Sling initially and Ice +/- Scapular-Y view – PO NSAIDs or APAP or Narcs (rare) – Degree of Separation determines – AC joint CS Injection type of dislocation – Rehab • Avoid developing Impingement • Type III – Non-Op or Surgery – If distal clavicle overrides acromion on Cross Arm ADduction test Surgery • Type IV-VI - Surgery – AC Joint Reconstruction
Vanderbilt Sports Medicine www.aafp.org AC Joint Sprain XR
Grade 2 Grade 3
Vanderbilt Sports Medicine Grade 4 Grade 5 Glenohumeral Instability
http://www.imageinterpretation.co.uk/shoulder.html http://emcow.files.wordpress.com/2012/09/shoulder-disloc1.jpg Vanderbilt Sports Medicine http://www.intechopen.com/source/html/40393/media/image6_w.jpg Glenohumeral Instability History Exam • Subluxation • Arm hanging limp at side – Popped back in w/o specific Tx • Inability to reach across body • Dislocation • Inability to externally rotate – Someone else reduces or specific arm technique used to relocate joint • Direction of Instability • Anterior Instability follows humeral head – Apprehension/Relocation tests • Sensitive & Specific for Fear, Not – ABduction-ER = Anterior (90%) Pain – Abduction = Inferior • Inferior Instability – Forward Elevation = Posterior – Sulcus on Traction tests • Posterior Instability – Posterior Jerk test Vanderbilt Sports Medicine Anterior Instability Apprehension and Relocation Tests
http://www.chiro.org/LINKS/FULL/Shoulder_Dislocation_in_Young_Athletes.html Vanderbilt Sports Medicine Posterior & Inferior Instability
Posterior Jerk Test Sulcus Sign with Traction Test
http://i1.ytimg.com/vi/gPuCikFKUzE/maxresdefault.jpg http://o.quizlet.com/Y8H2wK5Imz4g0bpp.9v3Pw_m.jpg Vanderbilt Sports Medicine Glenohumeral Instability Imaging Treatment • 4 views of the Shoulder • Reduce Dislocated Joint – AP Int. & Ext. Rotation & – Level I – Intra-articular lidocaine is Axillary & Scapular-Y view preferred to IV sedation • Axillary view prevents missing • Same success; Less complications (0.9 a posterior dislocation vs. 16.4%) Fitch RW, Kuhn JE. Acad Emerg Med 2008 • Classification • Sling Immobilization – Level I & II – Ext. Rot. may reduce recurrence; Req. 3 wks. (1/4 studies) Itoi et al. JBJS 2007 • Sling vs. Surgery (No studies Rehab vs. Sx) – Level I – Non-Op Tx has higher risk of recurrence (47 vs. 16%) Kirkley et al. Arthroscopy 1999 Vanderbilt Sports Medicine Kuhn JE, Dunn WR et al. J Shoulder Elbow Surg. 2011 Final Summary • Was there an injury/event? Or was it a process? – Injury/Event – Rot. Cuff Tear, Subacromial Bursitis, AC or GH Dislocation – Process – Impingement, Frozen Shoulder, Biceps Tendonitis, DJD • Do they have “Rest Pain”? – No – Impingement, Rotator Cuff Tear (after initiating pain), Prox. Biceps Tear – Yes – Subacromial Bursitis (rapid), Frozen Shoulder (gradual), DJD (constant), AC or GH Dislocation (acute) • Where does it hurt? Where does the pain go? What causes it? – AC-Lateral Neck, Subacromial Space-Lateral Brachium, Biceps-Ant. Brachium – Tendonopathy hurts with palpation, stretch, and contraction • Appropriate XR will adequately address most shoulder pain – Always include an A/P Int./Ext. Rotation views with an Axillary view – If Acute Rotator Cuff Tear suspected MRI – If Glenohumeral Instability Scapular-Y Vanderbilt Sports Medicine Questions or Comments
Vanderbilt Sports Medicine www.vanderbiltsportsmedicine.com
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